Medical History Form

Start your medical history form. This information will be used for the evaluation of your health and to ensure you qualify for weight loss surgery.

The form is extensive, but please try to answer as accurately and completely as possible. Please take your time and complete it carefully and thoroughly, and then, review it to be certain you have not left anything out.

All information will be kept confidential. Fields marked in red are required field.

MEDICAL HISTORY

Please list all medications and dosage that you are currently taking

List the Medical Professionals that are treating you. Please include full name, address and phone number for each Medical Professional you are seeing. Also Please let us know why you are seeing each doctor you list. Please include your Primary Care Physician, Heart Doctor, Therapist, Psychiatrist, or any other Medical Professional you are seeing on a regular basis

Please list any Medical Conditions you may have, be as honest and forthcoming as possible

Please list any prior surgery complications you may have had

Do you have Reflux Disease?

YESNO

Do you have High Blood Pressure?

YESNO

Do you have Degenerative Joint Disease?

YESNO

Do you have Urinary Stress Incontinence?

YESNO

Do you have High Cholesterol?

YESNO

Do you have Leg Swelling?

YESNO

Do you have Irregular Menstrual Periods?

YESNO

Do you have Diabetes?

YESNO

Do you use Insulin?

YESNO

Do you have Sleep Apnea?

YESNO

Do you use a C-Pap? (if you do please bring it with you for surgery)

YESNO

Do you use a B-pap? (if you do please bring it with you for surgery)

YESNO

Do you take medication for depression?

YESNO

*Optional

SYSTEM REVIEWS

Please indicate if you have or have had any of the following conditions:

Cardiovascular

Heart Attack

YESNO

Angina (Heart pain with activity)

YESNO

Rhythm Distrubance/Palpitations

YESNO

Congestive Heart Failure

YESNO

High Blood Pressure

YESNO

Ankle Swelling

YESNO

Varicose Veins

YESNO

Hemorrhoids

YESNO

Phlebitis

YESNO

Ankle/Leg Ulcer

YESNO

Heart Bypass/Valve Replacement

YESNO

Pacemaker

YESNO

Clogged Heart Arteries

YESNO

Rheumatic Fever/ Valve Damage

YESNO

Heart Murmur

YESNO

Irregular heartbeat

YESNO

Cramping in the legs when walking

YESNO

Other Symptoms

YESNO

Describe other Symptoms if you checked YES

Respiratiry

Asthma

YESNO

Emphysema

YESNO

Bronchitis

YESNO

Pneumonia

YESNO

Chronic Cough

YESNO

Tuberculosis

YESNO

Pulmonary Embolism

YESNO

Shortness of Breath

YESNO

Hypoventilation Syndrome

YESNO

Cough Up Blood

YESNO

Snoring

YESNO

Sleep Apnea

YESNO

Lung Surgery

YESNO

Lung Cancer

YESNO

Endocrine

Hyperthyroid (low)

YESNO

Hyperthyroid (high/overactive)

YESNO

Goiter - Enlarged Thyroid

YESNO

Parathyroid

YESNO

Elevated Cholesterol

YESNO

Elevated Triglycerides

YESNO

Low Blood Sugar

YESNO

Diabetes (managed by diet or pills)

YESNO

Diabetes (managed with insulin shots)

YESNO

Pre-Diabetes (with elevated blood sugar)

YESNO

Gout

YESNO

Endocrine Gland Tumor

YESNO

Cancer of the Endocrine Gland

YESNO

High Calcium Levels

YESNO

Abnormal Facial hair Growth

YESNO

Gastero-Intestinal

Heartburn

YESNO

Hiatal Hernia

YESNO

Ulcers

YESNO

Diarrhea

YESNO

Blood in Stool

YESNO

Changes in Bowel Habit

YESNO

Constipation

YESNO

Irritable Bowel Syndrome

YESNO

Colitis

YESNO

Crohn's Disease

YESNO

Hemorrhoids

YESNO

Fissure

YESNO

Rectal Bleeding

YESNO

Black Tarry Stool

YESNO

Polyps

YESNO

Abdominal Pain

YESNO

Enlarged Liver

YESNO

Cirrhosis/Hepatitis

YESNO

Gallbladder Problems

YESNO

Was your Gallbladder Removed?

YESNO

Jaundice

YESNO

Pancreatic Disease

YESNO

Unusual Vomiting

YESNO

Cancer

YESNO

Indicate what type of Cancer (Only if answer yes)

Gasterointestinal Surgery

YESNO

What type of surgery was performed? (if you answered YES)

Bladder / Kidney

Kidney Stones

YESNO

Blood in Urine

YESNO

Prostate Problems

YESNO

Kidney Failure

YESNO

Incontinence urinary

YESNO

PSA test in the last year?

YESNO

Burning sensation with urinating?

YESNO

Trouble Urinating

YESNO

Surgery on the bladder, kidney or prostate?

YESNO

What was the surgery for?

Cancer

YESNO

Musculoskeletal

Arthritis

YESNO

Where do you have arthritis?

Neck Pain

YESNO

Shoulder Pain

YESNO

Wrist Pain

YESNO

Back Pain

YESNO

Hip Pain

YESNO

Knee Pain

YESNO

Ankle Pain

YESNO

Foot Pain

YESNO

Musculoskeletal Cancer

YESNO

Type of Cancer - if applicable

Heel Pain

YESNO

Ball of Foot or Toe Pain

YESNO

Plantar Fasciitis

YESNO

Carpal Tunnel Syndrome

YESNO

Lupus

YESNO

Scleroderma

YESNO

Sciatica

YESNO

Autoimmune Disease

YESNO

Muscle Pain or Spasms

YESNO

Fibromyalgia

YESNO

Broken Bones

YESNO

Joint Replacement

YESNO

Nerve Injury

YESNO

Muscular Dystrophy

YESNO

Prior Musculoskeletal Surgery

YESNO

What type of surgery - if applicable

Head and Neck

Do you wear contacts or glasses?

YESNO

Vision Problems

YESNO

Hearing Problems

YESNO

Sinus Drainage

YESNO

Neck Lumps

YESNO

Swallowing Difficulty

YESNO

Do you wear Dentures or partials?

YESNO

Do you have oral sores?

YESNO

Hoarseness

YESNO

Head or Neck Surgery

YESNO

What type of surgery did you have?

Cancer in the Head or Neck area?

YESNO

Neurologic

Migrane headaches

YESNO

Balance Disturbance

YESNO

Convulsions or Seizures

YESNO

Weakness

YESNO

Stroke

YESNO

Alzheimer

YESNO

Loss of Vision from High Blood Pressure

YESNO

Multiple Sclerosis

YESNO

Have you ever been knocked unconscious?

YESNO

Do you have frequent severe headaches?

YESNO

Surgery for Neurologic Disorder

YESNO

Type of Surgery - is applicable

Cancer

YESNO

Skin

Rashes under skin folds?

YESNO

Keloids

YESNO

Poor Wound Healing

YESNO

Frequent Skin Infection

YESNO

Surgery for Skin related issues

YESNO

Type of Skin Surgery - if applicable

Skin Cancer

YESNO

Blood

Anemia (Iron Deficiency)

YESNO

Anemia (Vitamin B12 deficiency)

YESNO

HIV

YESNO

Low Platelets (thrombocytopenia)

YESNO

Lymphoma

YESNO

Swollen Lymph Nodes

YESNO

Superficial Blood Clot in the leg

YESNO

Deep Blood Clot in the leg

YESNO

Blood Clot in the Lungs (Pulmonary Embolism)

YESNO

Bleeding Disorder

YESNO

Have you received a blood transfusion?

YESNO

When did you have your blood transfusion? - if applicable

Blood and thinning medication use?

YESNO

Ginecology For women only. Men should skip it down to the next section of questions.

Infertility

YESNO

Are you pregnant?

YESNO

Uterine/Ovarian Cancer

YESNO

Surgery?

YESNO

What type of surgery did you have? - if applicable

Menstrual Irregularity?

YESNO

Menstrual Pain?

YESNO

Excessively Heavy Periods

YESNO

Do you plan to have more children?

YESNO

Are you postmenopausal?

YESNO

Date of menopause onset

Date of last pap smear

Date of last menstrual period

Age when you started menses:

How many pregnancies have you had?

How many children do you have?

How many miscarriages or abortions have you had?

Breast For women only. Men should skip it down to the next section of questions.

Lumps?

YESNO

Pain

YESNO

Fiberocystic disease

YESNO

Nipple Discharge

YESNO

Surgery?

YESNO

Cancer

YESNO

Psychiatric All patients (men and women) must answer all questions

Axiety

YESNO

Depression?

YESNO

What medication are you taking for depression? if applicable

Anorexia (starvation to control weight)

YESNO

Bulimia (vomiting to control weight)

YESNO

Bipolar Disorder

YESNO

Alcoholism

YESNO

Drug Dependency? (be honest it will not effect your chance of having surgery)

YESNO

What drugs are you dependent on? - if applicable

Schizophrenia

YESNO

Do you have any other psychiatric problems?

YESNO

Please list your other psychiatric problems here:

Have you ever been hospitalized for psychiatric problems?

YESNO

Have you ever attempted suicide?

YESNO

Have you ever been physically abused?

YESNO

Have you ever been sexually abused?

YESNO

Have you ever seen a psychiatrist or counselor?

YESNO

Have you ever taken medication for a psychiatric problem or depression?

YESNO

Have you ever been in a chemical dependancy program?

YESNO

*Optional

CONSTITUTIONAL

Fevers

YESNO

Night Sweats

YESNO

Anemia

YESNO

Weight Loss

YESNO

Chronic Fatigue

YESNO

Hair Loss

YESNO

Tabacco use

Do you smoke now?

YESNO

If YES, how many cigarettes and or packs per day?

Do you use snuff or chew?

YESNO

If YES, how frequently do you use snuff or chew?

For how many years have you used tobacco?

If you have quit, how long ago did you quit?

Alcohol use

Do you drink alcohol now?

YESNO

If YES, how many drinks per week?

If YES, how many drinks per month?

At what age did you start drinking alcohol?

If you have quit drinking, how long ago did you quit?

Is anyone concerned about the amount you drink?

YESNO

Caffeine use

Do you drink beverages that contain caffeine?

YESNO

How many caffeine beverages do you drink in a day?

Do you drink carbonated soda beverages?

YESNO

How many soda's do you drink in a day?

*Optional

PAST SURGICAL HISTORY AND MEDICATION

Past Surgical History

Please list any and all surgeries you have had including TYPE OF SURGERY, NAME OF SURGEON, NAME OF HOSPITAL, and DATE of surgery (please be as complete as possible)

Please list any and all medications you are currently taking, include NAME of the Medication, DOSE, HOW OFTEN you take the medication, and REASON for taking it.

Please list any and all ALLERGIES to medication, food, latex or anything else here. Also please include the type of reaction you have to the allergy.

Please list any and all diet programs you may have tried in the past, please include NAME of the program, WHEN and how long ago, TOTAL WEIGHT LOSS, and POUNDS REGAINED

*Optional

DAILY DIET

PLEASE COMPLETE THE FOLLOWING FOOD DIARY AS HONESTLY AND COMPLETELY AS POSSIBLE. YOU WILL FILL IN TWO FIELDS, ONE FOR A NORMAL WEEKDAY DAY AND ONE FOR A NORMAL WEEKEND DAY. INCLUDE THE FOOD YOU EAT, AMOUNT OF FOOD YOU CONSUMED, AND HOW THE FOOD WAS PREPARED. INCLUDE SNACKS AND BEVERAGES (WITH AMOUNTS CONSUMED).

WEEKDAY DAY - pick an average day you live during the work week

WEEKEND DAY - describe what you eat over a typical weekend day

*Optional

PSYCHOLOGICAL GENERAL WELL-BEING INDEX (PGWBI)

This section of the examination contains questions about how you feel and how things have been going with you. For each question select the answer which best applies to you.

How have you been feeling in general? (during the past month)

How often were you bothered by any illness, bodily disorder, aches or pains? (during the past month)

Did you feel depressed? (during the past month)

Have you been in firm control of your behavior, thoughts, emotions, or feelings? (during the past month)

Have you been bothered by nervousness or your "nerves" (during the past month)

How much energy, pop, or vitality did you have or feel? (during the past month)

I felt downhearted and blue (during the past month)

Were you generally tense or did you feel any tension? (during the past month)

How happy, satisfied, or please have you been with your personal life (during the past month)

Did you feel healthy enough to carry out things you like to do or had to do? (during the past month)

Have you felt so sad, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile? (during the past month)

I woke up feeling fresh and rested (during the past month)

Have you ever been concerned, worried, or had any fears about your health? (during the past month)

Have you had any reason to wonder if you were losing your mind, or losing control over the way you act, talk, think, feel or of your memory? (during the past month)

My daily life was full of things that were interesting to me (during the past month)

Did you feel active, vigorous, or dull, sluggish? (during the past month)

Have you been anxious, worried, or upset? (during the past month)

I was emotionally stable and sure of myself (during the past month)

Did you feel relaxed, at ease or high strung, tight, or keyed-up? (during the past month)

I felt cheerful, lighthearted (during the past month)

I felt tired, worn out, used up or exhausted (during the past month)

Have you ever been under or felt you were under any strain, stress or pressure (during the past month)

LEGAL

Now that you have completed the medical history form, please take a moment to look it over one last time before submitting the form. It is very important that the doctor's have a complete understanding of your health as they prepare for your surgery. Please enter your name if everything is correct. *